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Larraín D, Caradeux J. β-Human Chorionic Gonadotropin Dynamics in Early Gestational Events: A Practical and Updated Reappraisal. Obstet Gynecol Int 2024; 2024:8351132. [PMID: 38486788 PMCID: PMC10940029 DOI: 10.1155/2024/8351132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/06/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
In the last decade, the widespread use of transvaginal ultrasound and the availability of highly specific serum assays of human chorionic gonadotropin (hCG) have become mainstays in the evaluation of early pregnancy. These tests have revolutionized the management of pregnancies of unknown location and markedly reduced the morbidity and mortality associated with the misdiagnosis of ectopic pregnancy. However, despite several advances, their misuse and misinterpretations are still common, leading to an increased use of healthcare resources, patient misinformation, and anxiety. This narrative review aims to succinctly summarize the β-hCG dynamics in early gestation and provide general gynecologists a practical approach to patients with first-trimester symptomatic pregnancy.
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Affiliation(s)
- Demetrio Larraín
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
| | - Javier Caradeux
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
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Romero R. Giants in Obstetrics and Gynecology Series: a profile of Judith Vaitukaitis, MD, who made possible the early detection of pregnancy. Am J Obstet Gynecol 2019; 220:40-44. [PMID: 30591120 DOI: 10.1016/j.ajog.2018.11.1092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 11/10/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services.
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Nicolaus K, Jimenez-Cruz J, Bräuer DM, Lehmann T, Mothes AR, Runnebaum IB. Endometriosis and Beta-hCG > 775 IU/l Increase the Risk of Non-tube-preserving Surgery for Tubal Pregnancy. Geburtshilfe Frauenheilkd 2018; 78:690-696. [PMID: 30057425 PMCID: PMC6059851 DOI: 10.1055/a-0635-8453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/23/2018] [Accepted: 05/28/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction
Tubal pregnancy is the most clinically relevant form of ectopic pregnancy. Surgery consisting of laparoscopic salpingotomy is the therapeutic gold standard. This study looked at risk factors for non-tube-preserving surgery. The aim was to determine a cut-off value for beta-hCG levels, which could be used to predict the extent of tubal surgery.
Materials and Method
97 patients with tubal pregnancy who underwent primary salpingotomy in the Department of Gynecology and Obstetrics of Jena University Hospital between 2010 and 2016 were retrospectively analyzed. A prior medical history of risk factors such as adnexitis, ectopic pregnancy, tubal surgery, treatment for infertility and intrauterine pessary was included in the analysis. The study population was divided into two subgroups: (1) a group which underwent laparoscopic linear salpingotomy, and (2) a group which had laparoscopic partial tubal resection or salpingectomy. Risk factors for salpingectomy were determined using binary logistic regression analysis. Statistical analysis was done using SPSS, version 24.0, to identify risk factors for non-tube-preserving surgery.
Results
68 patients (70.1%) underwent laparoscopic salpingotomy and 29 patients (29.9%) had laparoscopic salpingectomy. The two groups differed with regard to age (p = 0.01) but not with regard to the parameters ‘gestational age’, ‘viability and rupture status of the ectopic pregnancy’ or ‘symptoms at presentation’. Patients who were known to have endometriosis prior to surgery or who were diagnosed with endometriosis intraoperatively were more likely to undergo salpingectomy (OR: 3.28; 95% CI: 0.9 – 10.8; p = 0.05). Calculated mean beta-hCG levels were higher in the salpingectomy group compared to the group who had tube-preserving salpingotomy (3277.8 IU/l vs. 9338.3 IU/l, p = 0.01). A cut-off beta-hCG value of 775 IU/l prior to surgery was predictive for salpingectomy with a true positive rate of 86.2% and increased the probability that salpingectomy would be necessary (OR: 5.23; 95% CI: 0.229 – 0.471; p = 0.005).
Conclusion
Endometriosis and a beta-hCG value of more than 775 IU/l significantly increased the risk for non-tube-preserving surgery in women with tubal pregnancy.
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Affiliation(s)
- Kristin Nicolaus
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Jorge Jimenez-Cruz
- Abteilung für Geburtshilfe und Pränatalmedizin, Universitatsklinikum Bonn, Bonn, Germany
| | - Dominik Michael Bräuer
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Thomas Lehmann
- Institut für Medizinische Statistik, Informatik und Dokumentation, Universitätsklinikum Jena, Jena, Germany
| | - Anke Regina Mothes
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Ingo B Runnebaum
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
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Optimal use of peri-operative human chorionic gonadotrophin concentrations to identify persistent ectopic pregnancy after laparoscopic salpingostomy: a retrospective cohort study. Reprod Biomed Online 2018; 36:361-368. [DOI: 10.1016/j.rbmo.2017.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 12/04/2017] [Accepted: 12/05/2017] [Indexed: 11/21/2022]
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Taran FA, Kagan KO, Hübner M, Hoopmann M, Wallwiener D, Brucker S. The Diagnosis and Treatment of Ectopic Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:693-703; quiz 704-5. [PMID: 26554319 DOI: 10.3238/arztebl.2015.0693] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Extrauterine pregnancy is a complication of the first trimester of pregnancy that arises in 1.3-2.4% of all pregnancies. METHODS This review is based on articles and guidelines retrieved by a selective PubMed search. RESULTS The presentation of extrauterine pregnancy is highly variable, ranging from an asymptomatic state, to pelvic pain that is worse on one side, to tubal rupture with hemorrhagic shock. 75% of tubal pre gnancies can be detected by transvaginal ultrasonography. In patients with a vital extrauterine pregnancy, the human chorionic gonadotropin concentration generally doubles within 48 hours. Laparoscopy is the gold standard of treatment. Two randomized, controlled trials comparing organ-preserving treatment with ablative surgery revealed no significant difference in pregnancy rates after the intervention, but precise details of the surgical procedures were not provided, and long-term fertility data are lacking. Metho - trexate therapy should be used only for strict indications. CONCLUSION Further randomized, controlled trials with longer follow-up will be needed to answer currently open questions about the potential for individualized surgical treatment and the proper role of pharmacotherapy.
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Kayatas S, Demirci O, Kumru P, Mahmutoglu D, Saribrahim B, Arinkan SA. Predictive factors for failure of salpingostomy in ectopic pregnancy. J Obstet Gynaecol Res 2013; 40:453-8. [DOI: 10.1111/jog.12187] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 05/15/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Semra Kayatas
- Department of Obstetrics and Gynecology; Zeynep Kamil Women's and Children's Diseases Training and Research Hospital; Istanbul Turkey
| | - Oya Demirci
- Department of Obstetrics and Gynecology; Zeynep Kamil Women's and Children's Diseases Training and Research Hospital; Istanbul Turkey
| | - Pinar Kumru
- Department of Obstetrics and Gynecology; Zeynep Kamil Women's and Children's Diseases Training and Research Hospital; Istanbul Turkey
| | - Didar Mahmutoglu
- Department of Obstetrics and Gynecology; Zeynep Kamil Women's and Children's Diseases Training and Research Hospital; Istanbul Turkey
| | - Bahar Saribrahim
- Department of Obstetrics and Gynecology; Zeynep Kamil Women's and Children's Diseases Training and Research Hospital; Istanbul Turkey
| | - Sevcan Arzu Arinkan
- Department of Obstetrics and Gynecology; Zeynep Kamil Women's and Children's Diseases Training and Research Hospital; Istanbul Turkey
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Selim MF. Does Salpingotomy for Tubal Ectopic Pregnancy Always Require Methotrexate Prophylaxis? J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abe T, Akira S, Negishi Y, Ichikawa M, Nakai A, Takeshita T. Relevance of declines in serum human chorionic gonadotropin levels to the management of persistent ectopic pregnancy. J Obstet Gynaecol Res 2010; 35:961-6. [PMID: 20149048 DOI: 10.1111/j.1447-0756.2009.01073.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To evaluate postoperative declines in serum human chorionic gonadotropin (hCG) levels (percentages of preoperative hCG levels) to rule out persistent ectopic pregnancy (PEP). METHODS A retrospective study was conducted on 50 patients who underwent laparoscopic salpingotomy between April 1995 and March 2008. The postoperative course was divided into four periods: (period A: days 1-2; period B: days 3-4; period C: days 5-6; and period D: days 7-8), and the postoperative serum hCG declines in the PEP and control groups (successfully treated patients) were compared. A cutoff value of serum hCG decline to rule out PEP was established by receiver operating characteristic (ROC) analysis. RESULTS Ten of the 50 patients (20%) were diagnosed with PEP. There were no differences in clinical findings or preoperative serum hCG levels between the two groups. From period C, the serum hCG decline in the control group was significantly greater than in the PEP group, and all individual serum hCG declines in the PEP group were outside the 95% confidence interval of the control group. Furthermore, analysis by ROC using a 14% decline in postoperative serum hCG as a cutoff revealed that the specificity and sensitivity of the test were equal to 100% from period C. CONCLUSION Declines in serum hCG during period C (days 5-6) constitute an important marker of the presence or absence of PEP. Decisions regarding a second intervention for PEP should be made by this time postoperatively.
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Affiliation(s)
- Takashi Abe
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
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Garbin O, Helmlinger C, Meyer N, David-Montefiore E, Vayssiere C. [Can medical treatment be the first-line treatment for most ectopic pregnancies? A series of 202 patients]. ACTA ACUST UNITED AC 2009; 39:30-6. [PMID: 20005640 DOI: 10.1016/j.jgyn.2009.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 11/07/2009] [Accepted: 11/12/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the efficacy and safety of a liberal policy of medical treatment for ectopic pregnancies (EUP). MATERIAL AND METHODS Retrospective study of EUP that received active management between January 1999 and December 2003. Patients with rupture or near-rupture and those who refused medical treatment received surgical treatment. Other patients were treated by methotrexate. RESULTS Two hundred and two EUP were managed; 26 % were treated surgically, 74 % medically. The success rate of medical treatment was 83 %. A ss-hCG threshold of 2526 IU/l was selected. Under this level, the success rate was 90.7 % compared with 68 % when it was higher (p=0.001). Cardiac activity tripled the failure rate. Morbidity with medical treatment consisted of an augmentation in transaminases in 18.8 % and one case of severe dermatosis (0.7 %). Almost half of the patients treated medically required hospitalizations. CONCLUSION The extension of medical treatment in our population to 74 % of all EUP yielded a high success rate, 83 %.
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Affiliation(s)
- O Garbin
- Service de gynécologie-obstétrique, pôle de gynécologie-obstétrique, hôpitaux universitaires de Strasbourg, SIHCUS-CMCO, 19, rue Louis-Pasteur, 67300 Schiltigheim, France.
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Hajenius PJ, Mol F, Mol BWJ, Bossuyt PMM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007; 2007:CD000324. [PMID: 17253448 PMCID: PMC7043290 DOI: 10.1002/14651858.cd000324.pub2] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Treatment options for tubal ectopic pregnancy are; (1) surgery, e.g. salpingectomy or salpingo(s)tomy, either performed laparoscopically or by open surgery; (2) medical treatment, with a variety of drugs, that can be administered systemically and/or locally by various routes and (3) expectant management. OBJECTIVES To evaluate the effectiveness and safety of surgery, medical treatment and expectant management of tubal ectopic pregnancy in view of primary treatment success, tubal preservation and future fertility. SEARCH STRATEGY The Cochrane Menstrual Disorders and Subfertility Group's Specialised Register, Cochrane Controlled Trials Register (up to February 2006), Current Controlled Trials Register (up to October 2006), and MEDLINE (up to October 2006) were searched. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing treatments in women with tubal ectopic pregnancy. DATA COLLECTION AND ANALYSIS Data extraction and quality assessment was done independently by two reviewers. Differences were resolved by discussion with all reviewers. MAIN RESULTS Thirty five studies have been analysed on the treatment of tubal ectopic pregnancy, describing 25 different comparisons. SURGERY Laparoscopic salpingostomy is significantly less successful than the open surgical approach in the elimination of tubal ectopic pregnancy (2 RCTs, n=165, OR 0.28, 95% CI 0.09, 0.86) due to a significant higher persistent trophoblast rate in laparoscopic surgery (OR 3.5, 95% CI 1.1, 11). However, the laparoscopic approach is significantly less costly than open surgery (p=0.03). Long term follow-up (n=127) shows no evidence of a difference in intra uterine pregnancy rate (OR 1.2, 95% CI 0.59, 2.5) but there is a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.47, 95% 0.15, 1.5). Salpingostomy alone is significantly less successful than when combined with a prophylactic single shot methotrexate (2 RCTs, n=163, OR 0.25, 95% CI 0.08-0.76) to prevent persistent trophoblast. MEDICAL TREATMENT Systemic methotrexate in a fixed multiple dose intramuscular regimen has a non significant tendency to a higher treatment success than laparoscopic salpingostomy (1 RCT, n=100, OR 1.8, 95% CI 0.73, 4.6). No significant differences are found in long term follow-up (n=74): intra uterine pregnancy (OR 0.82, 95% CI 0.32, 2.1) and repeat ectopic pregnancy (OR 0.87, 95% CI 0.19, 4.1). One single dose intramuscular methotrexate is significantly less successful than laparoscopic salpingostomy (4 RCTs, n=265, OR 0.38, 95% CI 0.20, 0.71). With a variable dose regimen treatment success rises, but shows no evidence of a difference compared to laparoscopic salpingostomy (OR 1.1, 95% CI 0.52, 2.3). Long term follow-up (n=98) do not differ significantly (intra uterine pregnancy OR 1.0, 95% CI 0.43, 2.4, ectopic pregnancy OR 0.54, 95% CI 0.12, 2.4). The efficacy of systemic single dose methotrexate alone is significantly less successful than when combined with mifepristone (2 RCTs, n=262, OR 0.59, 95% CI 0.35, 1.0). The same goes for the addition of traditional Chinese medicine (1 RCT, n=78, OR 0.08, 95% CI 0.02, 0.39). Local medical treatment administered transvaginally under ultrasound guidance is significantly better than a 'blind' intra-tubal injection under laparoscopic guidance in the elimination of tubal ectopic pregnancy (1 RCT, n=36, methotrexate OR 5.8, 95% CI 1.3, 26; 1 RCT, n=80, hyperosmolar glucose OR 0.38, 95% CI 0.15, 0.93). However, compared to laparoscopic salpingostomy, local injection of methotrexate administered transvaginally under ultrasound guidance is significantly less successful (1 RCT, n=78, OR 0.17, 95% CI 0.04, 0.76) but with positive long term follow up (n=51): a significantly higher intra uterine pregnancy rate (OR 4.1, 95% CI 1.3, 14) and a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.30, 95% CI 0.05, 1.7). EXPECTANT MANAGEMENT: Expectant management is significantly less successful than prostaglandin therapy (1 RCT, n=23, OR 0.08, 95% CI 0.02-0.39). AUTHORS' CONCLUSIONS In the surgical treatment of tubal ectopic pregnancy laparoscopic surgery is a cost effective treatment. An alternative nonsurgical treatment option in selected patients is medical treatment with systemic methotrexate. Expectant management can not be adequately evaluated yet.
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Affiliation(s)
- P J Hajenius
- Academic Medical Center, University of Amsterdam, Obstetrics and Gynecology (H4-205), Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.
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Natale A, Candiani M, Barbieri M, Calia C, Odorizzi MP, Busacca M. Pre- and post-treatment patterns of human chorionic gonadotropin for early detection of persistence after a single dose of methotrexate for ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2005; 117:87-92. [PMID: 15474251 DOI: 10.1016/j.ejogrb.2004.04.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2003] [Accepted: 04/13/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Given the great variability of human chorionic gonadotropin (HCG) levels after a single dose of methotrexate (MTX) for ectopic pregnancy, it remains complicated to identify cases undergoing persistence until a week from treatment. We evaluated whether pre-treatment patterns of HCG levels could be useful for an earlier detection of persistent trophoblast. STUDY DESIGN A retrospective study on 62 patients treated by a systemic single dose of methotrexate (50 mg/m(2)) for an ectopic pregnancy. Samples for HCG detection were obtained on days -2 and 0 before the therapy, on days +3, +7 and then weekly until values were undetectable. Patients were divided into three groups: Group U (up, meaning "increasing") and Group D (down, meaning "decreasing") when HCG levels on day 0 were respectively higher or lower than day -2 level of more than 20% and Group P (plateau) when the difference between day -2 HCG level and the level on day 0 was less than 20%. RESULTS All the patients of Group D underwent a complete resolution, with a percentage of 33.3% of cases who underwent an initial rise of HCG levels on day +3. The percentage of cases undergoing an initial rise of HCG levels in Group U patients was significantly higher than in Group P patients (60.0% versus 28.6%), but the resolution rate resulted similar in the two groups. For patients of Group P, an increase of HCG levels on day +3 was significantly correlated to the failure of the therapy. Indeed, comparing the cases with an immediate increase of HCG levels to the cases with immediate decrease of HCG levels on day +3, the persistence rate was 80% for the former and 12% for the latter (P < 0.0001). CONCLUSION An initial rise of HCG levels after the therapy does not seem to have a clinical relevance in Group D and Group U patients, it well correlates to trophoblastic persistence in Group P patients.
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Affiliation(s)
- Andrea Natale
- CUCESC-Centro Universitario di Chirurgia Endoscopica e Sperimentazione Clinica, Clinica L. Mangiagalli, II Department of Obstetrics and Gynecology, University of Milan, Via della Commenda 12, Milan 20122, Italy.
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Barnhart KT, Bader T, Huang X, Frederick MM, Timbers KA, Zhang JJ. Hormone pattern after misoprostol administration for a nonviable first-trimester gestation. Fertil Steril 2004; 81:1099-105. [PMID: 15066470 DOI: 10.1016/j.fertnstert.2003.08.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2003] [Revised: 08/26/2003] [Accepted: 08/26/2003] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate serial hormone concentrations in subjects treated with vaginally administered misoprostol for early pregnancy failure. DESIGN As part of a randomized clinical trial, serum was collected on treatment days 1, 3, 8, and 15. SETTING Multicenter clinical trial. PATIENT(S) Women with a nonviable first-trimester pregnancy. INTERVENTION(S) Serum concentrations of human chorionic gonadotropin (hCG), progesterone, and sex hormone binding globulin (SHBG) were evaluated. MAIN OUTCOME MEASURE(S) A logistic regression model was constructed to assess the associations of percent and complete expulsion of the gestational sac and/or successful management. RESULT(S) The percent change from the day of treatment until the first follow-up visit was predictive for complete expulsion for progesterone (P) (P<.005) and hCG (P<.005), but not for SHBG. The actual value was not significantly associated with complete expulsion or successful management. A decrease (day 1-3) of 79% for both hCG and P was associated with a 90% probability of complete passage of the gestational sac. A 90% probability of successful management was noted if P decreased by 78% on day 3 or 59% on day 7, or hCG decreased by 74% on day 3 or 78% on day 7 compared with pretreatment values. CONCLUSION(S) Percent change, but not absolute change, in serial hormone values are strongly associated with both the complete expulsion of the gestational sac with one dose of misoprostol and ultimate success.
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Affiliation(s)
- Kurt T Barnhart
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104-5509, USA.
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Billieux MH, Petignat P, Anguenot JL, Campana A, Bischof P. Early and late half-life of human chorionic gonadotropin as a predictor of persistent trophoblast after laparoscopic conservative surgery for tubal pregnancy. Acta Obstet Gynecol Scand 2003; 82:550-5. [PMID: 12780426 DOI: 10.1034/j.1600-0412.2003.00154.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND To determine if the early or late half-lives (T0.5) of human chorionic gonadotropin (hCG) can identify patients with persistent trophoblastic activity after conservative surgery for tubal pregnancy. DESIGN Prospective cohort study. SETTING Department of obstetrics and gynecology of a university hospital. METHODS All patients with a tubal pregnancy treated by laparoscopic salpingostomy between June 1997 and September 2000 were enrolled in the study. Postoperative sequential hCG sampling was performed at days 0, 2 (+/- 1) and 7 (+/- 2) and followed until levels were undetectable. Taking the biexponential hCG declining curve as a model, we calculated the early (days 0-2) and late (days 2-7) T0.5 hCG values. MAIN OUTCOME MEASURE To assess success or failure of surgical treatment. RESULTS Seventy-three patients with an ectopic pregnancy were managed by conservative surgery. Early and late T0.5 allowed us to identify 2/10 and 9/10 women, respectively, with persistent trophoblast. Late T0.5 levels revealed two patients with false-positive values, but one patient showed a secondary increase in hCG after day 7 (false-negative) despite a normal late T0.5. CONCLUSIONS Early and late half-lives of hCG do not identify all women at risk for persistent ectopic pregnancy. To exclude persistent trophoblast, postoperative serum hCG determination should be performed until levels are undetectable.
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Affiliation(s)
- Marie-Hélène Billieux
- Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.
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Lund CO, Nilas L, Bangsgaard N, Ottesen B. Persistent ectopic pregnancy after linear salpingotomy: a non-predictable complication to conservative surgery for tubal gestation. Acta Obstet Gynecol Scand 2002; 81:1053-9. [PMID: 12421174 DOI: 10.1034/j.1600-0412.2002.811110.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The drawback of conservative surgery for ectopic pregnancy (EP) is the risk of persistent trophoblast. The purpose was to characterize patients who develop persistent ectopic pregnancy (PEP) after salpingotomy for EP and to assess prognostic factors. METHODS The medical records of 417 patients treated by salpingotomy for EP were reviewed. Forty-eight (11.5%) patients were diagnosed with persistent EP. The data were analyzed using the Mann-Whitney U-test, Fischer's exact test or the chi2-test. RESULTS Of 417 women, 48 (11,5%) were treated for PEP by either repeat surgery (n = 25) or methotrexate (n = 23). Oral methotrexate failed in 4/19 cases while intramuscular (i.m.) methotrexate was successful in 4/4 cases. Women treated for PEP had a higher preoperative and a slower postoperative decline of serum human chorionic gonadotropin (hCG). Both the preoperative and the early postoperative hCG levels had a low diagnostic sensitivity (0.38-0.66) and specificity (0.74-0.77) for predicting PEP. In multivariate logistic analysis, none of the following clinical variables were predictive of PEP: duration of surgery, laparoscopic approach, history of previous EP, history of previous lower abdominal surgery, ruptured EP, pelvic adhesions, absence of products of conception at microscopy and hemoperitoneum. CONCLUSIONS Persistent ectopic pregnancy can neither be predicted from clinical variables nor from single measurements of hCG with an accuracy sufficient for clinical use.
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Affiliation(s)
- Claus Otto Lund
- Department of Obstetrics and Gynecology and Laparoscopic Unit, Hvidovre University Hospital, Copenhagen, Denmark.
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Natale A, Busacca M, Candiani M, Gruft L, Izzo S, Felicetta I, Vignali M. Human chorionic gonadotropin patterns after a single dose of methotrexate for ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2002; 100:227-30. [PMID: 11750970 DOI: 10.1016/s0301-2115(01)00480-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The great variability in human chorionic gonadotropin (HCG) levels after a single dose of methotrexate (MTX) for ectopic pregnancy makes it difficult to predict treatment failure. We describe different patterns of HCG levels. STUDY DESIGN Fifty patients were injected i.m. with 50mg/m(2) of MTX for an ectopic pregnancy. Venous blood samples for HCG detection were obtained on the day of treatment (day 0), day 3 and day 7 and weekly until values were undetectable. Patients were classified as: group 1, persistent pathology (n=11); group 2, complete resolution with a decrease of HCG levels at day 3 (n=30); group 3, complete resolution after a rise of HCG values at day 3 (n=9). Statistical analysis was performed using the Mann-Whitney non-parametric test with 95% confidence intervals. RESULTS Values of day 0 were similar for all the groups. HCG levels of group 3 decreased rapidly after day 3 and at day 7 they were significantly different from levels of group 1. Differences in HCG levels between groups 2 and 3 became indistinguishable from day 21. CONCLUSION The observation of patients undergoing resolution after an initial increase of HCG levels justify an expectant management for 1 week in clinically stable patients. The strategy to separate HCG curves in patients undergoing resolution may shed light on the different clinical responses to therapy for ectopic pregnancies. However, the phenomenon of the immediate rise of HCG should be better investigated.
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Affiliation(s)
- Andrea Natale
- II Department of Obstetrics and Gynecology, Centro Universitario di Chirurgia Endoscopica e Sperimentazione Clinica (CUCESC), University of Milan, Milan, Italy.
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Poppe WA, Vandenbussche N. Postoperative day 3 serum human chorionic gonadotropin decline as a predictor of persistent ectopic pregnancy after linear salpingotomy. Eur J Obstet Gynecol Reprod Biol 2001; 99:249-52. [PMID: 11788181 DOI: 10.1016/s0301-2115(01)00397-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the ability of preoperative clinical, ultrasonographic, intraoperative findings and pre-postoperative serum human chorionic gonadotropin (hCG) levels to predict persistent ectopic pregnancy (EP). STUDY DESIGN Retrospective cohorts study. SETTING Tertiary care, university hospital. In all, 61 women with EP treated with laparoscopic linear salpingostomy between January 1995 and December 1999. RESULT Out of 61 patients, 10 (9%) were diagnosed with a persistent EP. When compared with 51 (91%) successfully treated patients there were no differences in preoperative clinical and ultrasonographic findings, preoperative serum hCG levels and intraoperative findings. The postoperative decline of hCG levels were different in both groups. No case of persistent EP was found if the postoperative day 3 decline of hCG was more than 55%. CONCLUSION Postoperative serum hCG follow-up is important after salpingotomy to prevent persistent EP. A decline of less than 55% at day 3 predicts persistent EP and may select early cases for second line methotrexate therapy.
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Affiliation(s)
- W A Poppe
- Department of Obstetrics and Gynaecology, Universitair Ziekenhuis Gasthuisberg, Katholieke Universiteit Leuven, Herestraat 49, B-3000, Leuven, Belgium.
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18
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Gracia CR, Brown HA, Barnhart KT. Prophylactic methotrexate after linear salpingostomy: a decision analysis. Fertil Steril 2001; 76:1191-5. [PMID: 11730749 DOI: 10.1016/s0015-0282(01)02906-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare two strategies for managing women after linear salpingostomy for treatment of tubal pregnancy: observation and prophylactic methotrexate. DESIGN Decision analysis. SETTING Outpatient tertiary-care center. PATIENT(S) One thousand hypothetical women treated with a linear salpingostomy for ectopic pregnancy. INTERVENTION(S) Observation after salpingostomy and treatment of persistent ectopic pregnancy with a single dose of methotrexate (current standard of care) versus treatment with prophylactic methotrexate at the time of salpingostomy. MAIN OUTCOME MEASURE(S) Number of ruptured ectopic pregnancies, surgical procedures, complications, and cost for each group (observation vs. prophylaxis). RESULT(S) Prophylactic methotrexate results in fewer cases of tubal rupture (0.4% vs. 3.7%) and fewer procedures (1.9% vs. 4.7%) at a lower cost ($67.55 less/patient) compared with observation alone. Methotrexate-associated complications occur more frequently with prophylaxis (5.5% vs. 0.8%). Certain conditions change which strategy is preferable. Observation is the best strategy when the persistent ectopic pregnancy rate is <9%, the success of prophylaxis is <95%, the complication rate associated with methotrexate is >18%, or the rupture rate of persistent ectopic pregnancies is <7.3%. CONCLUSION(S) Prophylactic methotrexate at the time of linear salpingostomy for the treatment of ectopic pregnancy is preferable to observation as long as certain conditions exist.
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Affiliation(s)
- C R Gracia
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Barnhart K, Esposito M, Coutifaris C. An update on the medical treatment of ectopic pregnancy. Obstet Gynecol Clin North Am 2000; 27:653-67, viii. [PMID: 10958010 DOI: 10.1016/s0889-8545(05)70162-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Medical treatment of ectopic pregnancy with methotrexate has been shown to be effective and safe in appropriate patients. When considering medical management, the definitive diagnosis of an ectopic pregnancy and the assurance that the patient is a candidate are of paramount concern. An understanding of the mechanism of action and pharmacokinetics of methotrexate allows the clinician to better inform patients, recognize and treat side effects, and be cognizant when treatment is unsuccessful. Two common protocols, the "multi-dose" and the "single-dose" protocols, have excellent success rates; however, neither one of these is completely effective. The "multi-dose" protocol appears to have a higher success rate than the "single-dose" protocol.
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Affiliation(s)
- K Barnhart
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Medical Center, Philadelphia, USA
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20
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Hajenius PJ, Mol BW, Bossuyt PM, Ankum WM, Van Der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2000:CD000324. [PMID: 10796710 DOI: 10.1002/14651858.cd000324] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The diagnosis of ectopic pregnancy can now often be made by non-invasive methods due to sensitive pregnancy tests (in urine and serum) and high resolution transvaginal sonography, which have been integrated in diagnostic algorithms. These algorithms, in combination with the increased awareness and knowledge of risk factors among both clinicians and patients, have enabled an early and accurate diagnosis of ectopic pregnancy. As a consequence, the clinical presentation of ectopic pregnancy has changed from a life threatening disease to a more benign condition. This in turn has resulted in major changes in the options available for therapeutic management. Many treatment options are now available to the clinician in the treatment of tubal pregnancy: surgical treatment, which can be performed radically or conservatively, either laparoscopically or by an open surgical procedure; medical treatment, with a variety of drugs, that can be administered systemically and/or locally by different routes (transvaginally under sonographic guidance or under laparoscopic guidance); expectant management. The choice of a treatment modality should be based on short-term outcome measures (primary treatment success and reinterventions for clinical symptoms or persistent trophoblast) and on long-term outcome measures (tubal patency and future fertility). OBJECTIVES In the treatment of tubal pregnancy various types of treatments are available: surgical treatment, medical treatment and expectant management. In this review the effects of various treatments are summarized in terms of treatment success, need for reinterventions, tubal patency and future fertility. SEARCH STRATEGY The Cochrane Menstrual Disorders and Subfertility Group trials register and MEDLINE were searched. SELECTION CRITERIA Randomized controlled trials comparing treatments in women with ectopic pregnancy. DATA COLLECTION AND ANALYSIS Trial quality was assessed and data extracted independently by two reviewers. Differences were resolved by discussion with all reviewers. MAIN RESULTS Laparoscopic conservative surgery is significantly less successful than the open surgical approach in the elimination of tubal pregnancy due to a higher persistent trophoblast rate of laparoscopic surgery. Long term follow-up shows similar tubal patency rates, whereas the number of subsequent intrauterine pregnancies is comparable, and the number of repeat ectopic pregnancies lower, although these differences are not statistically significant. The laparoscopic approach is less costly as a result of significantly less blood loss and analgesic requirement, and a shorter duration of operation time, hospital stay, and convalescence time. Compared to laparoscopic conservative surgery (salpingostomy) local methotrexate is not a treatment option. Injection of this drug, both under laparoscopic guidance and under ultrasound guidance, is significantly less successful in the elimination of tubal pregnancy. Systemic methotrexate in a single dose intramuscular regimen is not effective enough in eliminating the tubal pregnancy compared to laparoscopic salpingostomy. This as a result of inadequately declining serum hCG concentrations after one single dose of methotrexate necessitating additional methotrexate injections or surgical interventions. If methotrexate primarily given in a multiple dose intramuscular regimen is compared with laparoscopic salpingostomy no large differences are found in medical outcomes, both short term and long term. However, this treatment regimen is associated with a greater impairment of health related quality of life and is more expensive, due to surgical interventions for clinical signs of tubal rupture, generating additional direct costs due to prolonged hospital stay. Furthermore, indirect costs due to productivity loss are higher. Only in patients with low initial serum hCG concentrations systemic methotrexate leads to costs savings compared to laparoscopic salpingostomy.
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Affiliation(s)
- P J Hajenius
- Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, PO Box 22700, Amsterdam, The Netherlands, 1100 DE.
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21
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Affiliation(s)
- J W Graczykowski
- Reproductive Health and Fertility Center, Rockford Health System, Illinois, USA
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22
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Abstract
Laparoscopic salpingostomy remains the definitive and universal treatment of ectopic pregnancy in patients who are hemodynamically stable and who wish to preserve their fertility. The reproductive performance after salpingostomy appears to be equivalent or better than salpingectomy, but the recurrent ectopic pregnancy rate may be slightly greater. Expectant management has a poor efficacy and unproven benefit in subsequent reproductive outcome. Its use should be limited to situations in which the ectopic pregnancy is suspected but cannot be detected by transvaginal ultrasound. Methotrexate is an alternative to surgical treatment in selected patients who fulfill strict inclusion criteria, including compliance with follow-up evaluation. A large, prospective, randomized trial with significant power is needed, however, to study the prognostic factors for methotrexate success. The most practical and efficient method of methotrexate administration is a single intramuscular injection. Those who do not meet the criteria for methotrexate therapy should be treated surgically, which can be done by laparoscopy. Interstitial pregnancy also can be treated with methotrexate. Otherwise, a cornual resection or salpingotomy can be done. Although, it is feasible by laparoscopy, the laparoscopic approach should be done only by those who have an expertise in laparoscopic suturing. Abdominal and ovarian pregnancies are best treated surgically. Further, the diagnosis usually is established by laparoscopy, and an appropriate surgical treatment can be conducted at the same time.
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Affiliation(s)
- T Tulandi
- McGill University, Montreal, Quebec, Canada.
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Yao M, Tulandi T. Surgical and medical management of tubal and non-tubal ectopic pregnancies. Curr Opin Obstet Gynecol 1998; 10:371-4. [PMID: 9818214 DOI: 10.1097/00001703-199810000-00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article highlights recent findings in the diagnosis and management of ectopic pregnancy. While the search for the ideal biochemical marker for ectopic pregnancy continues, new protocols have been described for the management of persistent ectopic pregnancy. The role of nuclear marker Ki-67 in trophoblastic proliferation and the only randomized trial to date involving systemic methotrexate and laparoscopic surgery are discussed. The management of cervical, interstitial and heterotopic pregnancies are reviewed.
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Affiliation(s)
- M Yao
- Department of Obstetrics and Gynaecology, McGill University, Montreal, Quebec, Canada
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Seifer DB. Persistent ectopic pregnancy: an argument for heightened vigilance and patient compliance. Fertil Steril 1997; 68:402-4. [PMID: 9314904 DOI: 10.1016/s0015-0282(97)00271-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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